Evaluating for Eating Disorders
Five simple ideas to open the dialogue.
Posted Feb 28, 2021
The last week in February is Eating Disorder Awareness Week. Eating disorders affect about 7.8% of the world population (Galmiche et al., 2019). Although less common than the comparatively ubiquitous anxiety or mood disorders, they deserve no less recognition by evaluators.
It's important to realize eating disorders aren't limited to anorexia or bulimia. The American Psychiatric Association (APA) officially recognized binge-eating disorder in the Diagnostic and Statistical Manual of Mental Disorder 5th Edition (DSM-5). There is also Avoidant-Restrictive Food Intake Disorder (ARFID), and Pica, conditions usually diagnosed in younger children.
ARFID is a condition of lack of interest in food or eating, restricted nutritional intake due to extreme sensitives to food textures, or fear of hazardous consequences of eating, like choking. Pica, another childhood condition, is the persistent consumption of non-food items. Speaking of age, popular culture seems to portray eating disorders as affecting the younger crowd. However, older adults can also be afflicted, for example, someone in midlife years who encountered a stressor that led to a relapse of bulimia that had been years in remission.
Still others may engage in dietary restrictions that don't fit any of the above. For instance, some college students, often female, drastically reduce healthy calories in order to drink alcohol excessively but not gain weight for it. This would be diagnosed as Unspecified Feeding or Eating Disorder.
Unfortunately, unless a practitioner is in the special niche of treating eating disorders, it seems the aforementioned lack of spotlight compared to other more common conditions often renders eating disorders a forgotten-about component of diagnostic evaluations. We're trained to ask about appetite, which can be affected by anxiety and mood. However, it may feel unnatural to ask about body image or relationships with food unless it's brought to the clinician's attention. Thankfully, we can naturally transition to these items on the heels of asking about appetite.
Exploring for eating disorders
As Eating Disorder Awareness Week winds down, hopefully psychology professionals were reminded of the importance of questioning about the conditions in their diagnostic interviews. ARFID and Pica-related behaviors are usually the parents' reason for evaluation/treatment. Anorexia, bulimia, and binge-eating disorder may not be obvious or the person may try to keep the matter hidden. If you're wondering how to incorporate questioning to assess for possible eating disorder/body image matters, consider the following:
- When asking about their appetite, if patients report eating minimally or eating a lot, it is important to explore what is driving the matter. Was the appetite change coincidental/unique to a depressive spell or onset of anxiety? If not, initiating a dialogue about the person's relationship to food is important. Are they thin but report frequent dieting? Are they overweight and report food as a go-to stress-buster?
- Asking clarifying questions about appetite increase/decrease is also helpful. For example, "Aaron, you mentioned that you've been hungrier lately. I just want to clarify, because sometimes people confuse hunger with simply eating more; are you hungrier, or do you feel compelled to eat, maybe even if you're already full?"
- It is common for interviewers to inquire about patients' self-image. This usually gleans information such as a person seeing themselves as a loser, victim, or having an inflated ego, for example. Integrating a question into this discussion specifically about their body image can be helpful. "You know, Joe/Jane, oftentimes body image has a lot to do with how someone feels about themselves, too. I'm wondering where you are with that."
- As for children/teens, guardians are often part of the interview process. It's helpful to take advantage of cross-checking with the guardians about concerns and presentations. Regarding eating-disordered behavior or body image concerns, after asking the child/teen, the clinician can simply say, "Mr./Mrs. So-and-So, do you have any concerns about Joe/Jane's eating or body-image?" This can also include asking about excessive exercise, or extremely careful dieting even though the person isn't of anorexic proportions. Such items may be indicative of the evolving of an eating disorder. If it's discovered a core belief of "I must be thin" or similar is behind it, being vigilant to evolving anorexia is important.
- If eating disorder/body image matters aren't currently at hand, have they ever struggled with anorexic, bulimic, or binge-eating behaviors? Even if they've been in remission for years, people can relapse into the pattern, and it is important to be vigilant to signs of recurrence, especially if a serious stressor is at hand.
If an eating disorder is present or suspected
Considering the physical/medical component of eating disorders, they take special training to work with. Most insurance companies will not reimburse a practitioner who does not have certification in eating disorder treatment. Therapists that do should be part of a team that includes primary care, nutritionists, psychiatry. If eating disorders aren't in one's repertoire, having some treatment sources to refer patients to for further evaluation/treatment is of the utmost importance. Someone enmeshed in anorexia could be headed towards a fatality if specialized treatment does not commence. Bulimic behavior can lead to serious digestive complications if not addressed. In other cases, as in most conditions, early intervention may predict better long-term treatment outcomes (Jones & Brown, 2016).
American Psychiatric Association. (2013). Diagnostic and statistical manual of mental disorders (5th ed.).
Galmiche, M., Déchelotte, P., Lambert, & G., Tavolacci, M.P. (2019). Prevalence of eating disorders over the 2000–2018 period: a systematic literature review. The American Journal of Clinical Nutrition, 109 (5), 1402–1413, https://doi.org/10.1093/ajcn/nqy342
Jones, M. & Brown, T. (2016). Why Early Intervention for Eating Disorders is Essential. National Eating Disorders Association Blog. https://www.nationaleatingdisorders.org/blog/why-early-intervention-eating-disorders-essential